B-2017-0327CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0327
923 BROOKGROVE IN CUPERTINO, CA 95014-4667 (375 39 026)
AMERICAN HVAC &
PLUMBING INC
CAMPBELL, CA 95008
OWNER'S NAME: HELMICK DANIEL M AND LIN YI-WEN
DATE ISSUED: 02/28/2017
OWNER'S PHONE: 408-646-2126
PHONE NO: (408) 440-0304
LICENSED D ONTR TOR'C DECLARATION
BUILDING PERMIT INFO:
License Class C-20 Lic. #946540
Contractor AMERICAN HVAC & PLUMBING INC Date 04/30/2018
X BLDG —ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
X MECH X RESIDENTIAL _ COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
REPLACE FURNACE & AC PACKAGE UNIT (SAME LOCATION -
I hereby affirm under penalty of perjury one of the following two declarations:
ROOF
i. I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
z. I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Sq. Ft Floor Area:
Valuation: $6000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
375 39 026
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We) agree to save indemnify and keep harmless the
City of Cupertino against liabilities, judgments, costs, and expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
Additionally, the applican erstands and will comply with all non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations the Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 2L28/2017
Issued by: Kim Dunbar
OWNER -BUILDER DECLARATION
Date: 02/28/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
1. I, as owner of the property, or my employees with wages as their sole
installed without first obtaining an inspection, I agree to remove all new materials for
compensation, will do the work, and the structure is not intended or offered for
inspection.
sale (Sec.7044, Business & Professions Code)
z. I, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 2/28/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance, as provided for by
I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code, for the performance of the work for which this
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(a) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cupertin unici al Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Se s 25505, 2 533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
r
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 2/28/2017
I certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws
I hereby affirm that there is a construction lending agency for the performance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is issued (Sec. 3097, Civ C.)
to enter upon the above mentioned property for inspection purposes. (We) agree
Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
Lender's Address
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
Code, Section 9.18.
1 understand my plans shall be used as public records.
Licensed
Signature Date 2/28/2011
Professional
CUPERTINO
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(akupertino.org MISIC
20
(PLUMBING F1k4FCUAMICA I MF7T VODTl AT 1-1,
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PROJECT ADDRESS12
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APN
OWNER NAME V„ a j
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CITY, STATE, ZIP
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CONTACT NAME
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CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT I:J CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME � 6Q i —
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LICENS NIUMBER
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LICENSE TYPE
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BUS. LIC #
5444
COMPANY NAME
E-MAIL
FAX
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PHONE
ARCHITECT/ENGINEER NAME
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LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRE,
CITY, STATE, ZIP
PHONE
USE OF 9SFD.IDUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA 1:11K6
PROJECT IN 13 YES
FLOOD ZONE V NO
IS TILE BLDG AN 13YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
a (
Leu` C-- V.+ c <— O c�
TOTAL VALUATION: '
RECEIVED -BY:
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to ng o is c ion. I authorize representatives of Cupertino to enter the above-iden ified property for inspection purposes.
Signature of Applicant/Agent: Date: (sl�
SUPPLEMENTAL INFORMATION REQUIRED
/ r 6
OFFICE USE ONLY
❑ OVER-THE-COUNTER
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❑ EXPRESS
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❑ STANDARD
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❑ LARGE
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❑ MAJOR
MEPMiscApp_201I.doc-J-evised 06121/11
CERTIFICATE OF COMPLIANCE
Alterations to Space Conditioning Systems (formerly CF -IR -ALT -HVAC) (Page 1 of 3)
Project Name: 0217-923 1 Date Prepared: 2017-02-28
A. General Information
CF1R-ALT-02 is applicable to multiple space conditioning systems contained within a single dwelling unit. When multiple dwelling units must be documented, use one
CF1R-ALT-02 document for each dwelling unit.
01
Project Name
0217-923
02
Date Prepared
2017-02-28
03
Project Location
923 Brookgrove Ln.
04
Building Type
Single family
05
CA City
Cupertino
06
Dwelling Unit Name
0217-923
07
Zip Code
95014
08
Dwelling Unit Conditioned
1432
Installing
Installing
Installing
Floor Area (ft)
Location or Area
by this SC
ducted
containing
system
Number of Space
entirely new
09
Climate Zone
4
10
Conditioning (SC) Systems in
1
component?
components?
feet of ducts?
duct system?
this Dwelling Unit:
Alteration Type
B. Space Conditioning (SC) System Information
01
02
03
04
05'
06
07
08
09
10
Is the SC
Installing a
SC System
SC System
CFA served
system a
refrigerant
Installing new SC
Installing
Installing
Installing
Identification or
Location or Area
by this SC
ducted
containing
system
more than 40
entirely new
entirely new
Name
Served
System (ft2)
system?
component?
components?
feet of ducts?
duct system?
SC system?
Alteration Type
System 1
Location 1
1355
Yes
Yes
Yes
No
No
No
Altered space
conditioning system
C. Extension of Existing Duct System, Greater Than 40 Feet (Section 150.2(b)1Diib)
This section does not apply to this project.
Registration Number: 217-A020065496A-000-000-0000000-0000
Registration Date/Time: 2017-02-28 09:57:30
HERS Provider: CaICERTS
CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version: 2016.1.005 Report Generated: 2017-02-28 09:58:18
Schema Version: rev 10/16
r- M _1
CERTIFICATE OF COMPLIANCE
CF1R-ALT 02-E
Alterations to Space Conditioning Systems (formerly CF -IR -ALT -HVAC) (Page 2 of 3)
D. Altered Space Conditioning System (Sections 150.2(b)1E and F)
01
02
03
04
05
06
07
08
09
10
11
12
Heating
Cooling
System
Heating
Altered
Heating
Minimum
Altered
Cooling
Minimum
Required
New or
Identification
System
Heating
Efficiency
Efficiency
Cooling
Cooling
Efficiency
Efficiency
Thermostat
Replaced
New Duct
or Name
Type
Components
Type
Value
System Type
Components
Type
Value
Type
Duct Length
R -Value
Central
All new
Central
All new
Less than or
System 1
packaged HP
heating
AFUE
81
k
pacaged AC
cooling
SEER
15
Setback
equal to 40
R-6
components
components
feet
Required Documentation:
CF2R-MCH-01-E - Space Conditioning Systems
- Duct insulation requirement for the new portions of supply -air and return -air ducts or plenums: R6 (CZ 1-10, 12 and 13) and R8 (CZ 11 and 14-16)
CF2R and CF3R-MCH-20-H - Duct Leakage Test required when heating or cooling components are installed in ducted systems, or when more than 40 ft of duct length is replaced
-Leakage rate compliance: <= 15% or <=10% leakage to outside, or seal all accessible leaks.
CF2R and CF3R-MCH-25-H Refrigerant Charge verification required when refrigerant containing components are installed or altered (applicable in CZ 2, 8-15).
CF2R and MR -MCH -23 Airflow Rate >= 300 CFM per ton required when MCH -25 is required.
Exceptions:
Duct systems registered with HERS provider as previously sealed are exempt from MCH -20 Duct Leakage Testing requirements.
Heating -only systems and Air Handler Furnace changes do not require verification of Air Flow MCH -23, or Refrigerant Charge MCH -25.
-Existing duct systems constructed, insulated or sealed with asbestos are exempt from MCH -20 Duct Leakage Testing requirements.
E. Entirely New or Complete Replacement Duct System, with or without Equipment Changeout (Sections150.2(b)1Diia and 150.2(b)1E, F)
This section does not apply to this project.
F. Entirely New or Complete Replacement Space Conditioning System (Section 150.2(b)1C)
This section does not apply to this project.
Registration Number: 217-A020065496A-000-000-0000000-0000
Registration Date/Time
2017-02-28 09:57:30
HERS Provider: CaICERTS
CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version: 2016.1.005 Report Generated: 2017-02-28 09:58:18
Schema Version: rev 10/16
t", a Ji
CERTIFICATE OF COMPLIANCE CF1R-ALT 02-E
Alterations to Space Conditioning Systems (formerly CF -IR -ALT -HVAC) (Page 3 of 3)
Documentation Author's Declaration Statement
1. 1 certify that this Certificate of Compliance documentation is accurate and complete.
Documentation Author Name:
Documentation Author Signature: /r
Hamm, Cuinn
(i te
Company:
Signature Date:
AMERICAN H V A C INC
2017-02-28 09:57:30
Address:
CEA/ HERS Certification Identification (if applicable):
17800 SODA SPRINGS ROAD
City/State/Zip:
Phone:
LOS GATOS CA 95033
408-440-0304
Responsible Person's Declaration statement
I certify the following under penalty of perjury, under the laws of the State of California:
1. The information provided on this Certificate of Compliance is true and correct.
2. 1 am eligible under Division 3 of the Business and Professions Code to accept responsibility for the building design or system design identified on this Certificate of Compliance (responsible designer).
3. That the energy features and performance specifications, materials, components, and manufactured devices for the building design or system design identified on this Certificate of Compliance conform to the
requirements of Title 24, Part 1 and Part 6 of the California Code of Regulations.
4. The building design features or system design features identified on this Certificate of Compliance are consistent with the information provided on other applicable compliance documents, worksheets,
calculations, plans and specifications submitted to the enforcement agency for approval with this building permit application.
5. 1 will ensure that a registered copy of this Certificate of Compliance shall be made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable
inspections. I understand that a registered copy of this Certificate of Compliance is required to be included with the documentation the builder provides to the building owner at occupancy.
Responsible Designer Name:
Responsible Designer Signature:
Hamm, Cuinn
C-706&'Or"
Company:
Date Signed:
AMERICAN H V A C INC
2017-02-28 09:57:30
Address:
License:
17800 SODA SPRINGS ROAD '946540
City/State/Zip:
Phone:
LOS GATOS CA 95033
408-440-0304
Digitally signed by Ca10ERTS. This digital signature is provided in order to secure the content of this registered document, and in noway implies Registration Provider
responsibility for the accuracy of the information.
Registration Number: 217-A020065496A-000-000-0000000-0000
Registration Date/Time
2017-02-28 09:57:30
HERS Provider: CaICERTS
CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version: 2016.1.005 Report Generated: 2017-02-28 09:58:18
Schema Version: rev 10/16
CUPERTINO
'DT 70,13n
0z
SMOKE I CARBON MONOXIDE ALARMS
OWNIER,CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014 3255
(408) 777-3228 - FAX (408) 777-1';:�R - ht dirimmear-i i—r-
7his affidavit is a self -cert for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with.20116 CRC Section 8314, R315, 2016 CBC Sections 420.6 and 907-2.11.2 'Where no interior access
for inspections are re(Tuired.
GENTERAL INFOR-MATION
Existing single-family and multi -family dwe-1-1-ii-igs shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the v aluation of additions, alterations, orrepairs to'existing divellingunite exceeds
51000.00, CRC Section R314, R315, and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or
Carbon Monoxide Alarms be h-Lstalleddn the following locations:
t AREA
SMOKE ALARM CO ALARNI
Outside of each separate sleeping area in the immediate vicinity of the(X
bedroom (s) - (Smoke a] =-ns shal-I not be 'located withiri 3 feet of bathroorn door)
X
L
On every level of a dwelling tinit including basements and habitable attics
X X
Within each sleeping room
X
Carbon Monoxide alarms are not required in d-,vellirigs whid-, do not contain fuel -burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
C�
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: in dwelling units with no commercial power supply, alarm(s) may be solely battery operated.
In existing dzvellin- units, alarms are permitted to be solely lely battery operated where repairs or alterations do
not result in the removal of wall and cea-ig finishes or there is no access by means of attic, basement or crawl
space. Refer to CRC Section 8314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is recused for
alarms which must be connected to the building wiring.
As owner of the above -referenced property, I hereby certify that the alarn-L(s) referenced above has/have been
installed in accordance wifl-t the manufacturer's instructions and in compliance vAtl-L the California Buijdirjo-
and California Residential Codes. The alarms specified below have been tested and are operational, as of the
date signed below.
Address: 923 Brookgrove Ln, Cupertino, CA 95014 Permit No. B-2017-0327
Specify Number of Alarms. W- Smoke Alarn-is. jr - 5 Carbon Mono-,dide Detectors
II-, ave read and arse to comply with the fern, s and conditions of this statement
Owner (or Ovmer Agent's) Name:
Daniel Helmick ftriatur-�- 0,fPet 4/19/17
........ -- .......... ...... ....... ....... — ...... - .Date --.— ........
Contractor Name:
Signature.... ..... ......... .......... .................. Llc,# ...................................... Date: ..... ..........
Smoke and COform.doc re -sed 01470/2017
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
.. COIv MUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
Daniel Helr ic$) 777-3228 • FAX (408) 777-3333 • building@cupertino.org
o` Dame K Permit No. B-2017-0327
Address 923 Brookgrove Ln, Cupertino, CA 95014
1. Is your real property a registered historicalsite? .
El Yes Civil Code Sections 1101.1 through 1101.8 do not appy. Skip the rest of the form and sign bottom of form.
o Go to Question 2.
2. Does your real property have a licensed plumber certifying that, due to the age or configuration of the property or its
plumbing, installation of w- ter -conserving plumbing Mures is not technically feasible?
Cf Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
E3 The licensed plumber's certification has been, provided to the Building Division.
Skip the rest of the form, and sign bottom of form.
X90 Go to Question 3.
3. Is water service permanently disconnected for your building?
E-1 Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest ofthe form and sign bottom of form
_ Io Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
n No Myreal property is built and available for use or occupancy after January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
Yes My real property is built and available for use or occupancy on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign
bottom of form..
5. Please check ONE of the following:
My property is a single-family residential real property. See Civil Code Section 1.101.4.
On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures
to be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1, 2017, all non-
compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
Ej My property is a muldjamily residential real property. See Civil Code Section 1101,5_
On and after January 1, 2014, specified building alterations or improvements shall require non- compliant
plumbing ft -tures to be replaced with water -conserving plumbing fixtures.
On or before January 1, 2019, all non compliant plumbing fixtures shall be replaced with water -
conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or
improvements).
C Ivlyproperty is a commercial real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or improvements shall require non compliant
plumbing fixtures to be replaced with -water-conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements).
Las the owner or owner's agent of tbis property, certify under penalty of perjury that non-compliant plumbing Mures :will be
replaced prior to date specified above with -water-conserving plumbing fixtures in accordance with Civil Code Sections 1101.1
through 1101.8, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's
installation requirements, and that the water -conserving plumb'fixtures comply with the requirements as indicated in the
table on the followine -raze. / /1 /) d /J
Owner or Owner Agent's Signature:
Upon completing and signing this Certificate, please return it to the
Date: 4/ 1 WZU I /
Division in order to final your building per t.
SB40 7 2015. doc reWsed 08126115
! r�� T -j 6—
CERTIFICATE OF VERIFICATION
FCF311-MCH-20-1-1
Duct Leakage Diagnostic Test
(Page 1 of 3)
Project Name: 0217-923
Enforcement Agency:
Cupertino
City of
Permit Number: B-2017-0327
Dwelling Address: 923 Brookgrove Ln.
City:
Cupertino
Zip Code: 95014
A. System Information
01
Space Conditioning System Identification or Name
System 1
02
Space Conditioning System Location or Area Served
Location 1
03
Building Type from CF -1R
Single family
04
Verified Low Leakage Ducts in Conditioned Space (VLLDCS)
Credit from CF1R?
No, credit is not taken
05
Verified Low Leakage Air Handling Unit Credit from CF1R?
No, credit is not taken
E06
Duct System Compliance Category
Alteration
e
MCH -20d - Complete Replacement or Altered Duct System
B. Duct Leakage Diagnostic Test
01
Condenser Nominal Cooling Capacity (ton)
3
02
Heating Capacity (kBtu/h)
49
03
Conditioned Floor Area served by this HVAC system (ft2)
1355
04
Duct Leakage Test Conditions
Test final
05
Duct Leakage Test Method
Total leakage
06
Leakage Factor
0.15
07
Air Handling Unit Airflow (AHUAirflow) Determination
Method
Cooling system method
08
Measured AHUAirflow
This field or section is not applicable
09
Calculated Target Allowable Duct Leakage Rate (cfm)
180
10
Actual Duct Leakage Rate from Leakage Test
Measurement (cfm)
133
11
Compliance Statement:
System passes leakage test
12
Notes:
Registration Number: Registration Date/Time: 2017-03-07 13:34:27 HERS Provider: CaICERTS
217-A020065496A-000-001-M20001A-M20A
CA Building Energy Efficiency Standards Report Version: 2016.1.005 Report Generated: 2017-03-07 13:34:58
2016 Residential Compliance Schema Version: rev 03/16
CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test (Page 2 of 3)
C. Additional Requirements for Compliance
01
System was tested in its normal operation condition. No temporary taping allowed.
02
Outside air (OA) duct connections to the central forced air duct system shall not be sealed/taped off during duct leakage
testing. OA ducts used for Central Fan Integrated (CFI) Indoor Air Quality ventilation systems, or Central Fan Ventilation
Cooling Systems, that utilize dampers that open only when OA is required and automatically close when OA is not required,
may configure the OA damper to the closed position during duct leakage testing.
03
If a complete replacement, all supply and return register boots were sealed to the drywall.
04
Building cavities were not used as plenums or platform returns in lieu of ducts.
05
If cloth backed tape was used it was covered with Mastic and draw bands.
06
All connection points between the air handler and the supply and return plenums are completely sealed.
07
If the system complies using the Smoke Test method, the smoke test was conducted in accordance with the requirements
of Reference Residential Appendix RA3.1.4.3.6. Systems that comply using smoke test shall not be included in sample
groups for HERS verification compliance.
08
Verification Status:
-Pass-.'all_applicablelrequirements are met
09
Correction Notes:
The responsible person's signature -on 'this compliance -document affirms that all applicable. requirements. in,this table -have
been met unless otherwise noted in the Verification Status and the -corrections Notes in.this table.
D. Determination of HERS Verification Compliance
All applicable sections of this document shall indicate compliance with the specified verification protocol requirements in order
for this Certificate of Verification as a whole to be determined to be in compliance.
01 1 Complies: All specified verification protocol requirements on this document are met.
Registration Number: Registration Date/Time: 2017-03-07 13:34:27 HERS Provider: CaICERTS
217-A020065496A-000-001-M20001A-M20A
CA Building Energy Efficiency Standards Report Version: 2016.1.005 Report Generated: 2017-03-07 13:34:58
2016 Residential Compliance Schema Version: rev 03/16
CERTIFICATE OF VERIFICATION CF3R-MCH-20-H
Duct Leakage Diagnostic Test (Page 3 of 3)
Documentation Author's Declaration Statement
1.1 certify that this Certificate of Verification documentation is accurate and complete.
Documentation Author Name:
David Garza
Documentation Author Signature:
oCilwa�
Company:
Date Signed:
Elements - E3
2017-03-07 13:34:27
Address:
CEA/ HERS Certification Identification (if applicable):
1718 Creek Drive
City/State/Zip:
Phone:
San Jose CA 95125
408-634-6690
Responsible Person's Declaration statement
I certify the following under penalty of perjury, under the laws of the State of California:
1. The information provided on this Certificate of Verification is true and correct.
2. 1 am the certified HERS Rater who performed the verification identified and reported on this Certificate of Verification (responsible rater).
3. The installed features, materials, components, manufactured devices, or system performance diagnostic results that require HERS verification
identified on this Certificate of Verification comply with the applicable requirements in Reference Appendices RA2, RA3, and the requirements
specified on the Certificate of Compliance for the building approved by the enforcement agency.
4. The information reported on applicable section."s of the Certificates) of Installation (MR) sighed and submitted by the persons) responsible for the
construction or installation conforms to the requirements specified on the Certificate(s) of Compliance (CFI_ R) approved by the enforcement agency.
S. I will ensure that a registered copy of this Certificate of,Verification shall be posted; or made available with the.building permit(s) issued for the
building, and made availabkto the enforcement.agency for all applicable inspections. I uncle rstand.that a -registered copy ofthis Certificate of
Verification is required to be included with the documentation the builder -provides to the building owner at occupancy.
Builder Or Installer Information As Shown On The Certificate Of Installation `
Company Name (Installing Subcontractor, General Contractor, or Builder/Owner):
AMERICAN H V A C INC
Responsible Builder or Installer Name:
CSLB License:
Cuinn Hamm
946540
HERS Provider Data Registry Information
Sample Group Number (if applicable):
Dwelling Test Status in Sample Group (if applicable)
Tested
HERS Rater Information
HERS Rater Company Name:
Elements - E3
Responsible Rater Name:
David Garza
Responsible Rater Signature:
0a"WN
fE
Responsible Rater Certification Number w/ this HERS Provider:
Date Signed:
CC2016094
2017-03-07 13:34:27
Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document, and in no way implies
Registration Provider responsibility for the accuracy of the information.
Registration Number:
217-A020065496A-000-001-M20001A-M20A
CA Building Energy Efficiency Standards
2016 Residential Compliance
Registration Date/Time: 2017-03-07 13:34:27 HERS Provider: CaICERTS
Report Version: 2016.1.005 Report Generated: 2017-03-07 13:34:58
Schema Version: rev 03/16